AGHS - Physician Billing FAQ

AGHS - Physician Billing FAQ

What Kinds of Insurance Does Atlantic General Health System Accept?

Atlantic General Health System and its employed providers participate with most major insurance carriers. Click here for a list of the insurances we currently accept.

What Is the Difference Between an HMO and a PPO?

Most of the time Health Maintenance Organizations (HMOs) tend to be group plans rather than individual plans. An HMO requires that you only see its doctors, and that you get a referral from your primary care physician before you see a specialist. They may have central medical offices or clinics or they may consist of a network of individual practices. Preferred Provider Organizations ( PPOs) have made arrangements for lower fees with a network of health care providers. PPOs give their policyholders a financial incentive to stay within that network. For example, a visit to an in-network doctor might mean you'd have a $10 co-pay. If you wanted to see an out-of-network doctor, you'd have to pay the entire bill up front and then submit the bill to your insurance company for an 80% reimbursement. In addition, you might have to pay a deductible if you choose to go outside the network, or pay the difference between what the in-network and out-of-network doctors charge. Preventive care services may not be covered under a PPO.

How Will My Bill Be Submitted?

If Atlantic General Health System participates with your insurance plan, we will submit a claim to that company for the care we provided. The reimbursement for the claim will then be sent directly to us. If there is a balance remaining after the insurance makes payment, you will receive a bill.

What Am I Responsible to Pay When I Visit My Doctor?

Your insurance plan will probably include a cost sharing feature where you pay a portion of the fee for the cost of medical care after the deductible has been satisfied.

Deductible - A fixed dollar amount that must be paid by the patient during the plan year before the insurance company will pay for covered services.

Co-Pays - Members pay a fixed dollar amount, such as $20 to visit the PCP, $30 to be treated by a Specialist, and $50 for an ED visit.

Co-Insurance - Members pay a fixed percentage of the cost. In this cost-share, the patient pays 20% and the insurance pays 80% of the allowed amount.

How Much Is My Medicare Deductible?

For the current deductible amount, please check the website.

Why Do I Have to Pay When I Have Insurance?

If you are covered by a participating insurance, we are contractually obligated to collect any co-pay, co-insurance or deductible from you. Prior to your visit, we will verify your insurance coverage and the amount you will be responsible to pay at the time of service. Medicare patients will pay their co-insurance at the time of service if they do not have a secondary insurance. Patients with Medigap coverage (insurance that covers their deductibles and/or co-insurance) will not pay at the time of service.

What Will I Have to Pay if AGHS Is Non-Participating with My Insurance?

If you are covered by an insurance that is non-participating with Atlantic General Health System, payment will be expected on the date of service. The Patient Accounting office will provide you with an itemized bill so that you can submit it to your insurance. Non-participating with the insurance means the provider would not accept any discounted reimbursement. The insurance will reimburse you directly, and you will be responsible for the bill from Atlantic General Health System.

What Does In-Network Provider Mean?

A network provider is a physician or group with contractual agreements with insurances which determine the allowed amount the physician may charge. The patient portion of the fee is determined by your insurance plan.

What Does Out-of-Network Mean?

An out-of-network provider is one not contracted with a particular health insurance plan. Generally if you see an out-of-network doctor, the insurance company will either pay less or not pay anything for services you receive from out-of-network providers. In addition you may have to pay the difference between what the in-network and out-of-network doctors charge.

What Does a Contractual Adjustment Mean?

This is the difference between the amount that the physician charges and what the contractual agreement is with your insurance. The patient is not responsible for this portion of the fee if it is a covered service.

How Much of the Bill Will My Insurance Company Cover?

Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.

Why Can't AGHS Staff Tell Me What My Insurance Will Cover?

Health insurance is important to all of us, but can be difficult to understand. The benefits, rules, and restrictions are determined by the terms of your policy, as well as the contracts AGHS has with the various insurance carriers. These questions, and others, that are specific to the coverage of your own insurance policy should first be directed to your insurance provider. Insurance contact information will be located on your insurance card, the insurance website or in your policy manual.

Why Do I Need to Bring My Insurance Card to My Appointment?

Your insurance card provides a large amount of information needed for billing purposes. This includes your membership number, effective date, group number, billing address, type of plan, co-pay amounts and often much more. Once we have the information in our system, we need to review your insurance card during subsequent visits to ensure that our information is current and verify that there have been no changes in your insurance plan. This prevents a lot of billing confusion, and limits the chances that we send you a bill because of incorrect insurance information.

I Have Insurance, so why Am I Receiving a Bill?

Insurances rarely pay 100% of physician services. The benefits, rules, and restrictions are determined by the terms of your policy.

What Do I Do if I Disagree with How Much the Insurance Paid?

If you disagree with the amount paid for a claim, contact the insurance company directly. If the insurance finds that an error was made on their part, make a note of the information and with whom you spoke. If the company states that the bill was paid correctly and you still disagree, ask the insurance company how to file an appeal..

Can You Re-bill My Insurance if they Did not Pay?

We can typically re-bill a claim within 180 days from the date of service for valid reasons such as data entry errors or inaccurate patient or insurance information. Another valid reason is if the insurance company processes the claim incorrectly by paying “out of network” benefits when we participate with your insurance company. We cannot re-bill a claim if the documentation in the medical record accurately supported the original diagnosis or procedure codes submitted to insurance.

What Does Coordination of Benefits Mean?

Coordination of benefits (COB) is used to establish the order in which health insurance plans pay claims when a patient has more than one insurance. We bill your primary insurance, then your secondary insurance. When health care benefits are coordinated, the insurance companies share the cost without overpaying.

Can You Bill My Child's Other Parent for the Visit?

If a patient is under the age of 18, the parent presenting the child for examination is considered the parent responsible for the bill. The parent presenting the child for medical treatment would be responsible for the out-of-pocket expense that is due at the time of service.

Why Am I Getting My Bill Months After I Was Treated?

Some insurance plans take up to 90 days or more to pay a claim. You will not receive your billing statement until your insurance company has processed your claim.

You Billed Me for a Doctor I Did Not See! Why?

There are several explanations for why the doctor's name might not be familiar to you:

  • Some insurance plans require when a patient sees a nurse practitioner or certified physician assistant that the claim is submitted under the supervising physician's name.
  • If you had surgery you may not recall or know the anesthesiologist’s name.
  • A bill may be submitted for the “technical or professional” portion of the services (such as x-rays, EKGs). The bill will have the name of the physician who oversees the facility or has read/reviewed your test or x-ray.

Can I Pay My Bill Online?

Yes, you may pay online. Click here to fill out the form.

Be sure to select the correct type of payment from the drop down screen: physician visit fee or hospital charge.

Can I Set Up a Payment Plan?

In some circumstances a payment plan can be arranged prior to services. Please call 410-641-9450 to ask about setting up a payment plan.

I Have Medicare, Why Am I Asked to Sign an ABN for Some Services?

You are asked to sign an Advance Beneficiary Notice (ABN) before services are furnished when Medicare will likely not pay for some or all of the services on the basis of Medicare's payment policies and guidelines. You can make an informed decision whether or not to receive the services for which you may have to pay out of pocket or through other insurance.